565801684-12-19-2023-29-AS-MARO-CYNS86-20231219123836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801684
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:39:01 PM

Document Has Been Signed on 12/19/2023 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SVS-SIMI VALLEY		FACILITY NUMBER:	565801684
ADMINISTRATOR:	LAURA WOOD		FACILITY TYPE:	775
ADDRESS:	2381 TAPO STREET, UNIT D		TELEPHONE:	(805) 582-1752
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 60		CENSUS: 15	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Laura Wood		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one year annual inspection today at 9:15 a.m. The last annual conducted at this facility was on 11/22/2022. Upon arrival, there were twelve (12) staff, and fifteen (15) clients present at the day program. The LPA met with Program Director, Laura Wood and the reason for the visit was explained. Entrance interview. At 9:25 a.m., the LPA along with the Program Director toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted during the plant tour: The day program operates from 8:00 a.m. to 1:00 p.m. The drivers will start participant pick-ups at 7:30 a.m. and begin drop-offs at 1:30 p.m. The day program is currently staffed appropriately with the necessary staff to consumer ratios. The facility has seven (7) activity rooms, four (4) client bathrooms, a staff room, and a kitchen area. Common Areas: At 9:28 a.m., the LPA observed the kitchen area to be clean and in good condition during time of visit. The refrigerator was observed with client’s snacks. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 12/08/2023. Carbon monoxide detectors are wired and operational at the time of the visit. (Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SVS-SIMI VALLEY	FACILITY NUMBER: 565801684
	VISIT DATE: 12/19/2023

NARRATIVE

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(Report Continued from LIC 809...)

The last fire inspection was completed on 12/02/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted on 11/12/2023. No bodies of water noted at the time of the visit. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with clients during time of visit. No obstructions or hazards were observed inside or out. Equipment used for activities was in good condition at the time of the visit.

Bathrooms: The LPA inspected the bathrooms for cleanliness. Restrooms were clean and trash cans have lids to protect clients from cross contamination. LPA observed a sufficient supply of paper towels. The hot water temperature was tested, and they measured between 109.5- and 115.2-degrees Fahrenheit at the time of the visit.

File Review: Records review began at 9:55 a.m.; eight (8) client records were reviewed for the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Individual Program Plans (IPP), and current needs and services plan. All client records were in order.

The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and valid first aid/CPR. The required annual training was met for all direct care staff. All staff records were in order.

Medications: There are no clients that are required to take medication while at day program. All medications are either taken before or after the day program.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance.

Exit interview conducted. No citations issued. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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